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LETTER TO THE EDITOR |
To the Editor.—
The recent policy statement concerning the Apgar score1 is internally contradictory and factually incorrect and should not have been presented as a policy statement of the sponsoring institutions. Clearly driven by an effort to oppose the use of low Apgar scores as litigious weapons, it suffers from persistent confusion between Apgar scores as indicators of asphyxia and Apgar scores as predictors of outcomes.
Concerning internal contradictions, we note the statement that "[t]he Apgar score has been used inappropriately in term infants to predict specific neurologic outcome." However, it is also acknowledged that "A retrospective analysis concluded that the 5-minute Apgar score remained a valid predictor of neonatal mortality" and "another study indicated that low Apgar scores at 5 minutes are associated with death or cerebral palsy, and this association increased if both 1- and 5-minute scores were low." Death and motor impairment are certainly specific neurologic outcomes.
The principal conveyed message, namely, that Apgar scores do not correlate with neurologic outcomes, is incorrect and directly contradicted by published evidence, including that presented in articles that are cited in the statement. No correlative study has failed to find an association between Apgar score and neurologic outcome. Several available studies do conclude that Apgar scores correlate with neurologic outcomes, in both term and premature infants, and argue that Apgar scores may be used as guidelines to the desirability of resuscitation.2–7 The authors argue that the Apgar score is reflective of condition, not etiology of condition, and that its predictive value is not absolute within certain time frames and ranges. This may be true, but it does not obviate the fact that correlation of low Apgar scores with negative outcome is indeed present at all time periods. The Collaborative Perinatal Project8 found the risk of cerebral palsy in surviving infants with a 1-minute score of 
3 to be 8 times the risk of those with scores of >6. Thirty-four percent of the infants with scores of 3 at 10 minutes died. Furthermore, we may be sure that the more subtle neurologic deficits of learning and behavioral difficulties have been consistently underestimated in studies that followed patients for limited time periods and with relatively simplistic criteria. This issue has not been addressed.
Although it is understandable that we wish to support our obstetrical colleagues in refuting the misuse of Apgar scores as tools of indictment of damaging (and remunerative) mismanagement, the issues of what they represent and what they predict need to be separated. The educational and operational implications of this article are not acceptable. To quote from a recent review cited by the authors, "We conclude that the Apgar system continues to be relevant to the prediction of neonatal outcome after almost half a century."9
FOOTNOTES
Statements appearing here are those of the writers and do not represent the offcial position of the American Academy of Pediatrics or its Committees. Comments on any topic, including the contents of PEDIATRICS, are invited from all members of the profession; those accepted for publication will not be subject to major editorial revision but generally must be no more than 400 words in length. The editors reserve the right to publish replies and may solicit responses from authors and others.
Please see www.pediatrics.org for instructions on submitting letters.
REFERENCES
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